Managing Surgical Risk, Budgets Is Trickier Than Ever
August 1, 2020 6 minutes read
EXECUTIVE SUMMARY
Surgery centers face multiple challenges as they navigate the new landscape of fewer cases, risk from COVID-19, and little government help.
- Many operating rooms were closed for two months because of the pandemic, and surgery centers still face economic issues.
- Anesthesiologists and other physicians helped hospitals during the COVID-19 crisis, including converting anesthesia machines into ventilators to help with the shortage.
- Many surgery centers expected loads of patients to present wishing to reschedule elective procedures that were put off during the lockdown. However, since resuming normal business, there are surgeons reporting smaller-than-expected caseloads.
As surgery centers and surgeons grapple with COVID-19 through the summer months, many have experienced lower-than-expected volumes. Meanwhile, the demands of taking more infection prevention measures and the risk of a second wave have resulted in organizations making emergency management a priority.
“You have to get organizations thinking not just about how it’s going to impact them in their bottom line, but also its wider community impact,” said Jayson Kratoville, MPA, interim director of the National Center for Security & Preparedness at the University at Albany, State University of New York. Kratoville spoke at a June 18, 2020, media conference hosted by Newswise.
Surgery centers have lost business during the COVID-19 public health emergency, but as they reopen many challenges remain. Plenty of operating rooms (ORs) were closed for months because of the pandemic, and they would take only emergency cases, says Stuart Fischer, MD, FAAOS, editor-in-chief of the website for American Academy of Orthopaedic Surgeons (AAOS). Fischer also is a surgeon at Summit Orthopedics and sports medicine in Summit, NJ. “Even simpler procedures like breast biopsies and others that needed to be done fairly quickly were put on hold,” Fischer says.
Some chose to put off elective surgeries voluntarily. Some government officials issued various orders regarding how to handle such procedures. “I’m in Texas, and the orders were pretty specific. If the person is not at risk of losing their lives or permanent harm or disability, then those surgeries could not be performed, and you could lose your license with the Texas Medical Board,” says Mary Dale Peterson, MD, MSHCA, FACHE, FASA, president of the American Society of Anesthesiologists. It was pretty forceful, and we’ve seen lots of furloughs and layoffs.”
Some physicians, including anesthesiologists, volunteered to help local health systems and were redeployed to intensive care units (ICUs). But most anesthesiologists saw a huge reduction in their work, adds Peterson, executive vice president and chief operating officer of Driscoll Health System of Corpus Christi, TX.
After the lockdown ended, surgeons figured there would be a backlog of elective procedures that needed to be performed. Everyone thought the main problem surgery centers would face this summer was finding ways to schedule new appointments for all these patients. That never happened for many surgery centers.
“The reality is that many people took time off from work and don’t want to take any more,” Fischer says. “Many lost jobs and health insurance. Many are afraid to go to the medical environment. There isn’t the caseload one might have expected.”
This phenomenon was common. “We heard there was going to be this humongous backlog of patients, charging back in, and I don’t think we’re seeing that backlog,” Peterson says. “We’ve been open for elective surgery for a month or so, and we’ve gotten through pretty much a lot of our backlog.” Surgeons will regain clients partly by letting people know about safety and infection prevention efforts. “First, [surgeons] should establish a program of safety and safeguards for surgery,” Fischer says. “This includes screening patients, pre-op testing, sanitizing the rooms, and testing their own personnel.”
Most centers will test staff regularly, and they will establish the proper institutional infection prevention regimen. Once they do that, surgeons will need to communicate their precautions to patients so patients will know the facility is as safe as it possibly can be, Fischer explains.
Even under optimal infection prevention conditions, there could be problems with patients and COVID-19. Patients could be infected shortly after their surgery, which could lead to bad outcomes.1
Stakes are high when it comes to surgery and COVID-19. Surgery patients who test positive for the virus a week before surgery or who test positive within 30 days after surgery are more likely to die within a month after the procedure. This is especially true for male patients. Researchers observed an overall mortality rate among surgery patients with COVID-19 to be 23.8%.1 “A patient could be COVID-negative at the time of surgery and then acquire it, or they could be positive before the surgery, but we didn’t know that until after the surgery,” says Haytham Kaafarani, MD, MPH, director of the Center for Outcomes & Patient Safety in Surgery and director of research at Massachusetts General Hospital in Boston.
Because of the pandemic, it takes surgery centers longer to clean rooms and sterilize them between cases, Fischer notes. Also, many facilities will not allow visitors to stay in a surgical waiting room. Some facilities require visitors to drop off patients and pick them up, he adds.
“Most facilities will require testing several days before elective surgery,” Fischer says. “After they take the test, they self-isolate and quarantine. That diminishes the risk of infection, somewhat.”
Surgery centers’ infection prevention precautions, concerns over the pandemic and its continued effect on individual patients, and worries about the economic viability of surgery practice, have made 2020 one of the most challenging years for the industry. For instance, some anesthesia and other healthcare companies were struggling even before COVID-19. Now, their situation is much worse, Peterson notes.
“One large staffing company was thinking about declaring bankruptcy,” she says. “There is concern out there because the dollars that the federal government put out in the CARES Act went to hospitals. There was no designated funding for physicians in the same way there was for hospital systems.”
The little funding that came through paycheck protection and Medicare was not close to the losses physicians incurred, Peterson adds. The American Society of Anesthesiologists is working on obtaining potential payments that are dedicated to physicians and anesthesiologists, recognizing their extra sacrifice.
“They not only had canceled elective surgeries, but many redeployed themselves, doing the highest-risk work, intubating COVID patients in ICUs,” Peterson explains. “They were in cities like New York and Boston when those places ran out of ICU ventilators. Our anesthesia machines have ventilators, so we worked with the Food and Drug Administration [FDA] to develop guidance and education for our members. Through the FDA’s green light, we could redeploy these machines to use for COVID patients as ventilators.”
Converting anesthesia machines into ventilators is straightforward, but requires anesthesiologists to work closely with ICU staff to manage the machines. Without help from anesthesiologists, some hospitals would have run out of ventilators. “We saw it coming, and we intervened just in the nick of time by redeploying those resources,” Peterson reports.
The American Society of Anesthesiologists has proposed anesthesiologists receive a 20% bump in payments for that type of service. “We would like retrospective pay for what we’ve done, as well as a mechanism to pay anesthesiologists for that service,” Peterson offers. The same thing could happen for physicians who worked with COVID-19 patients, which led them to miss out on regular cases, she adds.
As surgery centers and physicians struggle with the aftermath of the first wave of the pandemic, they are bracing for a potential double-whammy this fall.
“If hospitals are overwhelmed again, you would see disaster planning come into play again, and that would be very unfortunate,” Peterson says. “Not only is it affecting the livelihood of physicians, but it also impacts patients. A number of patients had heart attacks and strokes and didn’t receive the care they needed during the pandemic.”
For instance, there was double the rate of ruptured appendices during that period because people were not coming into the emergency room as often, Peterson explains.
“We need to get word out to the public that they should come in for needed care, and care should only be delayed for so long,” she says. “We’ve learned a lot; we’ve learned how to deploy resources, and we can manage patients better in the ICUs now.”
REFERENCE
- COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: An international cohort study. Lancet 2020 May 29;S0140-6736(20)31182-X. doi: 10.1016/S0140-6736(20)31182-X. [Online ahead of print].
Surgery centers face multiple challenges as they navigate the new landscape of fewer cases, risk from COVID-19, and little government help.
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